Liability Waiver Laser Teeth Whitening

1. Client Infomation *
Pre- Teeth Whitening Questions
2. Have you tried teeth whitening in the past? What have you tried and when? *
3. Are you teeth sensitive to hot and cold beverages? *
Teeth Whitening Expectations
DaVinci Teeth Whitening safely removes stains caused by food, beverages, tobacco, medicine, and aging. For the ultimate whitening effect on your teeth, you have the option to perform up to 3 whitening sessions at a time.

*When whitening, you might feel a slight tingle.
*DaVinci products will not damage existing dental work.
*DaVinci products will remove stains from existing dental work but will not whiten them beyond original color.
*Everyone's teeth respond differently and have their own natural "stop" point for whitening results.
*Teeth may feel temporary sensitivity; sensitivity is typically minor and gone within 24 hours. You may choose to purchase desensitizing treatment with your whitening. 
* You may experience temporary gum irritation, which is prevalent in client that brush abrasion from brushing teeth within 4 hours whitening.

DaVinci Products
DaVinci products offer enamel strengthening qualities. It is organic plant and mineral based containing NO animal by-products. Active ingredients is a Food Grade Hydrogen Peroxide.
To maintain healthy teeth and gums, it is recommended that you visit your dentist on a regular basis. If you have allergies or a allergic reaction to peroxide or glycerin, teeth whitening is not recommended. If you have diabetes, heart conditions, pregnant, and/ or currently breastfeeding you may want to consult with your doctor prior to using whitening products. Ask use for our list of ingredients if you have concerns. Any existing mouth sores may feel temporary irritation during and/ or after whitening. 

* Satisfaction is guaranteed at time of service, no refunds will be given after payment of services which is deemed satisfaction of results.
Customer Signature * if you are under 16, parent consent is required. *
Parent/Guardian Signature